Acute Massive Lower Gastrointestinal Bleeding From a Dieulafoy Lesion in the Anorectal Junction
Dieulafoy's lesions are one of the rarest causes of lifethreatening gastrointestinal bleeding. These lesions account for 1-2% of the causes of gastrointestinal bleeding, especially where the source cannot be identified. We report a case of a 63-year-old woman presented with massive lower gastrointestinal bleeding secondary to an Anorectal Dieulafoy lesion. In this report, we present our experience using operative approach to control bleeding from Anorectal Dieulafoy lesion after failure of endoscopic approach, along with review of literature.
Dieulafoy's disease is one of the rarest causes of lifethreatening gastrointestinal bleeding, characterized by a submucosal arterial lesion associated with mucosal defect. The first Dieulafoy’s lesion was described by Paul Georges Dieulafoy (1839-1911), most commonly occurring in the stomach and less commonly in the rectum, colon, small bowel and anorectal junction. Anorectal Dieulafoy has increasingly been recognized as an important cause of rectal bleeding. It can be diagnosed with different methods, like endoscopy, red cell scan and angiography studies. Treatment options depend on the mode of presentation, site of the lesion, and availability of expertise. The conventional method of treatment is stitching the bleeding source, but the treatment of choice is endoscopic haemostatic procedure with a success rate reaching up to 90%.
On local examination by anoscopy, there was a mix of blood clots and fresh blood per rectum with no local cause. Resuscitation was started with 4 units of PRBC, followed by EGD which was negative for upper GI bleeding. Furthermore, colonoscopy failed to localize and control the lower GI bleeding due to poor bowel preparation and massive active bleeding. Next, the patient was shifted to the radiology department to have a CT angiography where they localized the bleeding from a small rectal arteriole but failed to embolize it due to technical difficulty.
Dieulafoy’s lesion is characterized by large tortuous arteriole most commonly in the sub-mucosa of the stomach wall that erodes and bleeds. It can cause gastric haemorrhage, but it is relatively uncommon. There are different theories on the pathophysiology of Dieulafoy’s lesion. One theory of spontaneous bleeding is that sub-mucosal venous pulsation damages the epithelium and leads to local ischemia.
Managing Dieulfoy’s lesions is challenging due to the encountered difficulty in localizing the sight of bleeding. Therapeutic endoscopy is the procedure of choice for managing the Dieulfoy’s lesions. There are variable endoscopic techniques to control the lesions, such as laser photocoagulation, injection sclerotherapy, bipolar-monopolar electrocoagulation, hero clipping, band ligation, and Adrenaline injections.
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